Bilateral iliac and popliteal arterial thrombosis in a child with focal segmental glomerulosclerosis

Thromboembolic complications (TECs) are clinically important sequelae of nephrotic syndrome (NS). The incidence of TECs in children is approximately 2%–5%. The veins are the most commonly affected sites, particularly the deep veins in the legs, the inferior vena cava, the superior vena cava, and the renal veins. Arterial thrombosis, which is less common, typically occurs in the cerebral, pulmonary, and femoral arteries, and is associated with the use of steroids and diuretics. Popliteal artery thrombosis in children has been described in cases of traumatic dissection, osteochondroma, Mycoplasma pneumoniae infection, and fibromuscular dysplasia. We report of a 33-month-old girl with bilateral iliac and popliteal arterial thrombosis associated with steroid-resistant NS due to focal segmental glomerulosclerosis. Her treatment involved thrombectomy and intravenous heparinization, followed by oral warfarin for 8 months. Herein, we report a rare case of spontaneous iliac and popliteal arterial thrombosis in a young child with NS.

Infected Aortic Aneurysm caused by Mycobacterium bovis after Intravesical Bacillus Calmette-Guérin Treatment for Bladder Cancer

A 70-year-old man presented with lower back pain and cyanotic changes in his left lower extremity. He was diagnosed with infected aortic aneurysm and infectious spondylitis. He had received intravesical Bacillus Calmette-Guérin (BCG) therapy up to 1 month before the onset of symptoms. The aneurysm was excised and an aorto-biiliac interposition graft was performed. Mycobacterium tuberculosis complex was cultured in the surgical specimens. Real-time polymerase chain reaction (PCR) targeting the senX3-regX3 region, and multiplex PCR using dual-priming oligonucleotide primers targeting the RD1 gene, revealed that the organism isolated was Mycobacterium bovis BCG. The patient took anti-tuberculosis medication for 1 year, and there was no evidence of recurrence at 18 months follow-up.

Anatomical Features and Early Outcomes of Endovascular Repair of Abdominal Aortic Aneurysm from a Korean Multicenter Registry

Purpose:

To introduce a nation-based endovascular aneurysm repair (EVAR) registry in South Korea and to analyze the anatomical features and early clinical outcomes of abdominal aortic aneurysms (AAA) in patients who underwent EVAR.

Materials and methods:

The Korean EVAR registry (KER) was a template-based online registry developed and established in 2009. The KER recruited 389 patients who underwent EVAR from 13 medical centers in South Korea from January 2010 to June 2010. We retrospectively reviewed the anatomic features and 30-day clinical outcomes.

Results:

Initial deployment without open conversion was achieved in all cases and procedure-related 30-day mortality rate was 1.9%. Anatomic features showed the following variables: proximal aortic neck angle 48.8±25.7° (mean±standard deviation), vertical neck length 35.0±17.2 mm, aneurysmal sac diameter 57.2±14.2 mm, common iliac artery (CIA) involvement in 218 (56.3%) patients, and median right CIA length 34.9 mm. Two hundred and nineteen (56.3%) patients showed neck calcification, 98 patients (25.2%) had neck thrombus, and the inferior mesenteric arteries of 91 patients (23.4%) were occluded.

Conclusion:

Anatomical features of AAA in patients from the KER were characterized as having angulated proximal neck, tortuous iliac artery, and a higher rate of CIA involvement. Long-term follow-up and ongoing studies are required.

Quantitative Assessment of Foot Blood Flow by Using Dynamic Volume Perfusion CT Technique: A Feasibility Study

PURPOSE

To demonstrate the feasibility of foot blood flow measurement by using dynamic volume perfusion computed tomographic (CT) technique with the upslope method in an animal experiment and a human study.

MATERIALS AND METHODS

The human study was approved by the institutional review board, and written informed consent was obtained from all patients. The animal study was approved by the research animal care and use committee. A perfusion CT experiment was first performed by using rabbits. A color-coded perfusion map was reconstructed by using in-house perfusion analysis software based on the upslope method, and the measured blood flow on the map was compared with the reference standard microsphere method by using correlation analysis. A total of 17 perfusion CT sessions were then performed (a) once in five human patients and (b) twice (before and after endovascular revascularization) in six human patients. Perfusion maps of blood flow were reconstructed and analyzed. The Wilcoxon signed rank test was used to prove significant differences in blood flow before and after treatment.

RESULTS

The animal experiment demonstrated a strong correlation (R(2) = 0.965) in blood flow between perfusion CT and the microsphere method. Perfusion maps were obtained successfully in 16 human clinical sessions (94%) with the use of 32 mL of contrast medium and an effective radiation dose of 0.31 mSv (k factor for the ankle, 0.0002). The plantar dermis showed the highest blood flow among all anatomic structures of the foot, including muscle, subcutaneous tissue, tendon, and bone. After a successful revascularization procedure, the blood flow of the plantar dermis increased by 153% (P = .031). The interpretations of the color-coded perfusion map correlated well with the clinical and angiographic findings.

CONCLUSION

Perfusion CT could be used to measure foot blood flow in both animals and humans. It can be a useful modality for the diagnosis of peripheral arterial disease by providing quantitative information on foot perfusion status.

Percutaneous Aspiration Embolectomy Using Guiding Catheter for the Superior Mesenteric Artery Embolism

OBJECTIVE

To evaluate the technical feasibility and clinical outcome of percutaneous aspiration embolectomy for embolic occlusion of the superior mesenteric artery (SMA).

MATERIALS AND METHODS

Between January 2010 and December 2013, 9 patients with embolic occlusion of the SMA were treated by percutaneous aspiration embolectomy in 2 academic teaching hospitals. The aspiration embolectomy procedure was performed with the 6-Fr and 7-Fr guiding catheter. Thrombolysis was performed with urokinase using a multiple-sidehole infusion catheter. The clinical outcome was investigated retrospectively.

RESULTS

Superior mesenteric artery occlusion was initially diagnosed by computed tomography (CT) in all patients, and all patients had no obvious evidence of bowel infarction on CT scan. Percutaneous aspiration embolectomy was primarily performed in 6 patients, and thrombolysis was initially performed in 3 patients. In 3 patients who received primary thrombolysis, percutaneous aspiration was undertaken because the emboli were resistant to urokinase. Complete angiographic success was achieved in 6 patients and partial angiographic success was accomplished in 3 patients. One patient underwent bowel resection. One patient died of whole bowel necrosis and sepsis, and 8 patients survived without complications.

CONCLUSION

Percutaneous aspiration embolectomy is a useful tool in recanalization of embolic occlusion of the SMA in select patients.

Surgical Treatment of Infected Aortoiliac Aneurysm

Purpose:

Infected aneurysms of the abdominal aorta or iliac artery (IAAA) are rare but fatal and difficult to treat. The purpose of this study was to review the clinical presentations and outcomes of IAAA and to establish a treatment strategy for optimal treatment of IAAA.

Materials and Methods:

Electronic medical records of 13 patients treated for IAAA at Seoul National University Hospital between March 2004 and December 2012 were retrospectively reviewed.

Results:

Mean age was 64.2 (median 70, range 20–79) years. Aneurysms were located in the infrarenal aorta (n=7), iliac arteries (n=5), and suprarenal aorta (n=1). Seven patients underwent excision and in situ interposition graft, 3 underwent extra-anatomical bypass, and 1 underwent endovascular repair. One patient with endovascular repair in an outside hospital refused resection, and only debridement was done, which revealed tuberculosis infection. One staphylococcal infection was caused by iliac stenting. Mycobacterium was the most common pathogen, followed by Klebsiella, Salmonella, and Staphylococcus. There were 3 in-hospital mortalities and the causes were sepsis in 2 and aneurysm rupture in 1. The 3 extra-anatomic bypasses were all patent after 5-year follow-up.

Conclusion:

IAAA develops from various causes and various organisms. IAAA cases with gross pus were treated with extra-anatomic bypass, which was durable. In situ reconstruction is favorable for long term-safety and efficacy, but extensive debridement is essential.

Open Surgical Repair of Abdominal Aortic Aneurysm Coexisting with Horseshoe Kidney

Horseshoe kidney (HSK) is the most common congenital abnormality of the urologic system encountered during abdominal aortic aneurysm (AAA) surgery. Here, the authors report a case of AAA coexisting with HSK that was successfully treated by open surgery. Two accessory renal arteries of 2.5 mm and 3.1 mm were reimplanted. One of the implanted arteries later occluded and infarct of the isthmus developed, but there was no impairment of renal function. The authors discuss the complexity of the surgical treatment of AAA coexisting with HSK, and place focus on which accessory renal arteries should be reconstructed.

Different Recurrence Rates Between Pediatric and Adult Renal Transplant for Immunoglobulin A Nephropathy: Predictors of Posttransplant Recurrence

OBJECTIVES

The purpose of this study was to investigate immunoglobulin A nephropathy recurrence rate after transplant in children and adults and to identify recurrence rates by clinical progression before transplant.

MATERIALS AND METHODS

There were 56 patients with immunoglobulin A nephropathy who had renal transplant between 1989 and 2005. We categorized recipient age into < or ≥ 20 years at transplant. Each age category was divided into 2 levels based on recurrence.

RESULTS

The recurrence rate was higher in patients aged < 20 years(53.8%) than ≥ 20 years. Proteinuria was more frequently diagnosed in patients aged < 20 years (57.1% vs 25.0%; P = .047). In patients aged ≥ 20 years, the duration of dialysis was 4.55 months in the recurrence group and 17.78 months in the no recurrence group (P = .032). Time from progressive symptoms to renal replacement therapy was significantly shorter in patients aged ≥ 20 years with recurrence than patients aged ≥ 20 years with no recurrence. The univariate relative risk of recurrent immunoglobulin A nephropathy after transplant was 9.8 for recipients aged ≥ 20 years who had progressive symptoms to renal replacement therapy < 24 months (P = .046).

CONCLUSIONS

Patients aged < 20 years had more rapid disease progression to end-stage renal disease and a higher recurrence rate after transplant than patients aged ≥ 20 years. If patients aged ≥ 20 years progress rapidly from progressive symptoms to renal replacement therapy, renal transplant may be considered after 24 months because of high recurrence risk.

Inadvertent vascular injury of the aorta or vena cava caused by acupuncture

Major visceral vascular injury after acupuncture is a rare but serious complication. We recently treated two patients with an inferior vena cava or an abdominal aorta injury caused by acupuncture. Although both patients underwent successful surgical repair, the highly invasive nature of the operations led to complications, including infection and chyle leakage. Vascular surgeons should be aware that acupuncture can cause serious damage to the vena cava or aorta due to direct injury or subsequent infection.

Repeated cessation and resumption of resistance training attenuates increases in arterial stiffness

Although high-intensity resistance training (RT) increases arterial stiffness, removing weightlifting stimuli returns arterial stiffness to baseline levels within relatively short periods during 4-8 weeks. This study investigates the effects of repeated RT cessation and resumption on arterial stiffness. Eighteen young healthy subjects were randomly assigned to a group that performed continuous RT (CRT, n=9) and a group that performed periodic RT (PRT, n=9). Both groups performed RT at 75% of one repetition maximum for 3 days per week. The CRT group continuously trained for 16 weeks, whereas the PRT group performed 3 cycles of 4 weeks training, with 2 weeks detraining intervals between cycles. The carotid-femoral pulse wave velocity in the CRT group significantly increased (P<0.05) at 4, 6, 10, 12, 16 and 20 weeks from baseline, whereas in the PRT group it significantly increased (P<0.05) after 4, 10 and 16 weeks from baseline, and was significantly lower (P<0.05) than that of the CRT group after 6, 10, 12, 16 and 20 weeks. Muscle mass and strength in the both groups significantly increased after 16 weeks from baseline and persisted for 20 weeks (P<0.05). These results suggest that PRT, including short-term repeated cessation and resumption, attenuates increases in arterial stiffness.

Effect of imatinib mesylate and rapamycin on the preformed intimal hyperplasia in rat carotid injury model

PURPOSE

Intimal hyperplasia (IH) is the main cause of restenosis or occlusion after vascular procedures. Imatinib mesylate and rapamycin are known to prevent IH. The purpose of this study was to evaluate the effect of these drugs on the regression of preformed IH in rat carotid injury model.

METHODS

IH was established in rat carotid arteries using a balloon catheter. The drug effects were assessed in vitro on proliferation, migration, and apoptosis of vascular smooth muscle cells (VSMC) in the neointima. And in vivo studies were carried out in 4 groups: imatinib, rapamycin, combined, and no medication. After 2-week oral medication, morphometric analysis evaluated the number and density of neointimal cells, intima-to-media (I/M) ratio and cross-sectional area. Cell proliferation, apoptosis, and collagen changes were also investigated by immunohistochemical staining (IHCS).

RESULTS

Imatinib and rapamycin significantly inhibited VSMC proliferation and migration, and promoted apoptosis in vitro. In morphometric analysis, the number and density of neointimal cells decreased significantly in all medication groups compared with control group (P < 0.01). However, there was no significant difference in neointimal cross-sectional area and I/M ratio among groups. In IHCS, imatinib and rapamycin inhibited neointimal cell proliferation significantly. However, there was no significant change in cell apoptosis and collagen composition.

CONCLUSION

Combined treatment of with imatinib and rapamycin induced reduction of cell mass in preformed intimal hyperplasia, but failed to induce regression of intimal mass in this short-term medication study. Further studies will be needed with additional strategies of inducing lysis of the extracellular matrix.

Current Status of the Retrieval Rate of Retrievable Vena Cava Filters in a Tertiary Referral Center in Korea

PURPOSE

The purpose of this study was to review the daily practice of inferior vena cava filters (IVCFs) in a tertiary referral center in Korea and to reveal the retrieval rate and the methods for improving it.

MATERIALS AND METHODS

Through the electronic medical record system, a retrospective review was performed on 115 consecutive patients who underwent placement of retrievable IVCFs between February 2000 and January 2011 in Seoul National University Hospital.

RESULTS

IVCF placement was done in 115 cases (113 patients). There were 68 men (59.1%), and the mean age was 58.5±15.5 years (range, 10-96 years). The affiliated departments were Vascular Surgery (57 cases, 49.6%), and Internal Medicine (20 cases, 17.4%). Advanced malignancy was the most commonly associated disease (n=30, 26%). The indications for IVCF placement were categorized; absolute indications in 36 cases (31.3%), relative indications in 78 cases (67.8%), and prophylactic use in 1 case (0.9%). The most common indications were thrombolysis/thrombectomy for iliocaval deep vein thrombosis (DVT) (n=55, 47.8). Of the 115 filters, 68 were retrieved (retrieval rate, 59%). The most common cause of non-retrieval was chronic high risk of venous thromboembolism in 24 patients (51%), followed by residual proximal DVT (n=7, 15%), and negligence by unknown reasons (n=6, 13%).

CONCLUSION

To improve the retrieval rate, the number of follow-up losses to vascular specialists must be decreased, which can be achieved by establishment of a dedicated IVC filter clinic, implementation of a filter registry, and regular education for medical teams and patients along with their families.

The outcomes of percutaneous versus open placement of peritoneal dialysis catheters

BACKGROUND

Peritoneal dialysis catheters (PDCs) can be inserted by a percutaneous, open surgical, or laparoscopic approach. Considerable controversy surrounds the mode of catheter placement and its impact on technical success. We compared the complications and survival characteristics of PDCs that were inserted by the open approach versus those inserted percutaneously.

METHODS

We reviewed the outcomes of 167 patients who received PDCs between September 2009 and February 2012. Of these, 89 were placed percutaneously and 78 were placed by open surgical techniques. The mechanical complication rates, including catheter bleeding, wrapping, migration, leakage, and technical failure of intraperitoneal placement were compared between the two groups. Additionally, peritonitis episodes, exit site infection rates, and tunnel infection rates were compared between groups.

RESULTS

The incidence of one or more previous intra-abdominal surgeries was significantly higher in the open group (4.5 percutaneous vs 21.7 % open; P = 0.001). Although the overall number of complications did not differ between the two groups, the incidence of early mechanical complications (11.2 vs 0 %; P = 0.002) and the number of catheter removals due to mechanical complications (7.9 vs 1.3 %; P = 0.047) were higher in the percutaneous group. Of the 15 mechanical complications in the percutaneous group, one third were due to technical failures compared to none in the open group (5.6 vs 0 %; P = 0.034). The 1 year survival rate of the PDCs for the percutaneous and open groups was 89.9 and 93.3 %, respectively (P = 0.249).

CONCLUSIONS

The placement modality did not affect catheter survival. However, early mechanical complications, including technical failures, were more frequent in the percutaneous group, despite the proportion of patients with a history of one or more previous intra-abdominal surgeries being significantly lower in that group. The direct visualized open method of catheter insertion may provide the most reliable and secure access for a PDC.

Massive thromboembolism owing to the left ventricular thrombus associated with the hypereosinophilic syndrome

A 39-year-old man presented with cough, chest discomfort, and weight loss. On the basis of the patient history and laboratory findings, he was diagnosed with the hypereosinophilic syndrome. Transthoracic echocardiography revealed a large thrombus in the left ventricle. Medical treatment with anticoagulation and immunosuppression was commenced immediately. Fourteen days after the initial diagnosis, the patient presented with acute pain in his right leg. Computed tomographic angiogram showed embolic occlusion of the infrarenal abdominal aorta and bilateral iliac (including common, external, and internal iliac) arteries. Emergent thromboembolectomy and left ventricular thrombectomy were performed. The postoperative course was uneventful, and the patient has undergone follow-up for 2 months without any evidence of recurrence of thromboembolism.

Tissue responses to stent grafts with endo-exo-skeleton for saccular abdominal aortic aneurysms in a canine model

OBJECTIVE

We evaluated the effect of close contact between the stent and the graft on the induction of endothelial covering on the stent graft placed over an aneurysm.

MATERIALS AND METHODS

Saccular abdominal aortic aneurysms were made with Dacron patch in eight dogs. The stent graft consisted of an inner stent, a expanded polytetrafluoroethylene graft, and an outer stent. After sacrificing the animals, the aortas with an embedded stent graft were excised. The aortas were inspected grossly and evaluated microscopically.

RESULTS

The animals were sacrificed at two (n = 3), six (n = 3), and eight months (n = 2) after endovascular repair. In two dogs, the aortic lumen was occluded at two months after the placement. On gross inspection of specimens from the other six dogs with a patent aortic lumen, stent grafts placed over the normal aortic wall were covered by glossy white neointima, whereas, stent grafts placed over the aneurysmal aortic wall were covered by brownish neointima. On microscopic inspection, stent grafts placed over the normal aortic wall were covered by thin neointima (0.27 ± 0.05 mm, mean ± standard deviation) with an endothelial layer, and stent grafts placed over the aneurysmal aortic wall were covered by thick neointima (0.62 ± 0.17 mm) without any endothelial lining. Transgraft cell migration at the normal aortic wall was more active than that at the aneurysmal aortic wall.

CONCLUSION

Close contact between the stent and the graft, which was achieved with stent grafts with endo-exo-skeleton, could not enhance endothelial covering on the stent graft placed over the aneurysms.

Clinical significance of type I endoleak on completion angiography

Purpose

Type I endoleak is known to be associated with sac enlargement and occasional rupture, therefore, the treatment of type I endoleak is recommended at the time of diagnosis. The aim of this study was to identify the significance of early type I endoleak found on completion angiography.

Methods

Between January 2000 and December 2012, a total of 86 patients underwent endovascular abdominal aortic aneurysm repair (EVAR) and 10 patients (11.6%) were diagnosed with type Ia endoleak on completion angiography. Clinical and radiologic data were reviewed retrospectively.

Results

Of the 10 patients, two underwent EVAR with custom-made stent-grafts in the initial stage and both of them needed immediate treatment: one case involved open repair while the other involved insertion of an additional stent-graft. In 8 patients, the amount of leakage decreased after repeated balloon molding. They were managed conservatively and followed up with computed tomography angiography within 2 weeks after EVAR. In 7 of the 8 cases, type Ia endoleaks disappeared. In one patient with a persistent endoleak and a folded posterior wall of the stent-graft, coil embolization was performed 1 week after EVAR. With a median follow-up of 12 months (range, 1-61 months), no patients showed recurrence of type I endoleak or sac expansion.

Conclusion

Type I endoleaks diagnosed on completion angiography sealed spontaneously in 7 of 10 patients (70.0%). In cases of decreased amounts of leakage after balloon molding, simple observation may be an alternative to repetitive procedures. The long-term follow-up of patients with self-sealed type I endoleaks is mandatory.

Different Responses of Neointimal Cells to Imatinib Mesylate and Rapamycin Compared with Normal Vascular Smooth Muscle Cells

Purpose:

This study was designed to investigate whether vascular smooth muscle cells (VSMC) from the neointima showed any different response to anti-proliferative agents, such as rapamycin or imatinib mesylate, compared to VSMCs from normal artery.

Materials and Methods:

Intimal hyperplasia was made by carotid balloon in jury in male rats. Neointimal cells at 4 weeks after injury and normal VSMCs were extracted by enzymatic isolation method and cultured. Cell viability and proliferation were tested in VSMCs from injured left carotid artery and uninjured right carotid artery. Tests were repeated with rapamycin, imatinib mesylate or both in various concentrations.

Results:

Rapamycin decreased cell viability only at a high concentration of 10⁻⁵ M in uninjured VSMCs. Combined drugs decreased cell viability at a lower concentration of 10⁻⁷ M in uninjured VSMCs, and at a higher concentration of 10⁻⁵ M in neointimal cells. Overall, rapamycin showed cytocidal effects at a high concentration of 10⁻⁵ M, whereas imatinib did not. Cell proliferation of neointima was significantly decreased along with the drug concentration. Cell proliferation of uninjured VSMCs was significantly decreased at higher drug concentrations. Combined drug therapy showed synergistic effects. Overall, neointimal cells are more susceptible to the antiproliferative effects of the drugs.

Conclusion:

Neointimal cells from the injured carotid artery are more susceptible to the antiproliferative effect of imatinib and rapamycin. Both drugs can be a used for the prevention of intimal hyperplasia, which could be investigated through further in vivo studies.

Intimal hyperplasia in loop-injured carotid arteries is attenuated in transglutaminase 2-null mice

Arterial restenosis frequently develops after open or endovascular surgery due to intimal hyperplasia. Since tissue transglutaminase (TG2) is known to involve in fibrosis, wound healing, and extracellular matrix remodeling, we examined the role of TG2 in the process of intimal hyperplasia using TG2-null mice. The neointimal formation was compared between TG2-null and wild-type (C57BL/6) mice by two different injury models; carotid ligation and carotid loop injury. In ligation model, there was no difference in intimal thickness between two groups. In loop injury model, intimal hyperplasia developed in both groups and the intimal/medial area ratio was significantly reduced in TG2-null mice (P = 0.007). TG2 was intensely stained in neointimal cells in 2 weeks. In situ activity of TG2 in the injured arteries steadily increased until 4 weeks compared to uninjured arteries. Taken together, intimal hyperplasia was significantly reduced in TG2-null mice, indicating that TG2 has an important role in the development of intimal hyperplasia. This suggests that TG2 may be a novel target to prevent the arterial restenosis after vascular surgery.